


Prognosis

by J_Baillier



Series: You Go To My Head [13]
Category: Sherlock (TV), Sherlock Holmes & Related Fandoms
Genre: Angst, Autism Spectrum, Bullying, Career Angst, Communication, Don't copy to another site, Gen, Malignant collegiality, Medical School, Medical student Sherlock, Medicine, POV Sherlock Holmes, Patient communication, Patient safety, Sherlock is so young and stubborn and abrasive, Social Anxiety, Social Scripting, Whistle-blowing
Language: English
Status: Completed
Published: 2019-09-21
Updated: 2019-10-07
Packaged: 2020-10-25 08:27:56
Rating: Teen And Up Audiences
Warnings: No Archive Warnings Apply
Chapters: 3
Words: 9,354
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/20721197
Author URL: https://archiveofourown.org/users/J_Baillier/pseuds/J_Baillier
Summary: Year 2000, Cambridge University. Sherlock Holmes is a medical student whose difficulties in getting along with his peers have caught the attention of the teaching staff.





	1. The Second Year

**Author's Note:**

> [[an index and guide to all my Sherlock stories](https://archiveofourown.org/works/25011148)]
> 
> All hail the skilled beta of this story, 7PercentSolution.

> _“**When providing references for colleagues, your comments must be honest and justifiable; you must include all relevant information which has a bearing on the colleague’s competence, performance, reliability and conduct**”  
__— _GMC Good Medical Practice, Second Edition, July 1998 – The duties of a doctor registered with the General Medical Council

She extends her hand and he shakes it, disliking the dampness of the skin since she's just used hand disinfectant.

Her grip is firm and brief. "Call me Sharon."

"Sherlock Holmes," he offers in reciprocation.

She doesn't need his permission to call him by his first name, of course — he's a second-year medical student, while she is a world-renowned neurosurgeon: Sharon Medyar, MD, FRCS, OBE, winner of the Langley prize and a regular keynote speaker at all the conferences of her field. Sherlock knows everything there is to know about her academic credentials and her particular areas of expertise when it comes to intracranial surgery. He knows little about the rest of her life, and that's fine. He doesn't care about any of that. From an interview in The Sunday Times magazine section about her charity work in Myanmar he did learn that she comes from an Iranian, non-medical immigrant family. He wonders what her parents had thought of her plan to seek a medical career.

Being sent here to the neurosurgical outpatient clinic of Addenbrookes Hospital should feel like a reward for a student in the stage Sherlock has reached, but he recognises it for the test that it is. It's also a warning, an attempt to discourage him.

"Have a seat," Mrs Medyar — Sharon — prompts him. Mrs, not doctor, since she is a surgeon. She points to a chair somewhere between where she is seated, and two chairs presumably reserved for patients and their family members. Her clinic nurse had introduced himself earlier and has now disappeared to find some equipment they'll need.

The neurosurgeon takes a moment to frown at the computer screen; from her mouse movements and keystrokes Sherlock can tell she's logging in to the system. Then, she leans back in her chair. "So, Doctor Murray tells me you are interested in a career in neurosurgery, and that your marks so far are exemplary."

"Yes," Sherlock responds, unsure what else to answer. He arranges his hands into his lap, resists the urge to fidget and stim. Unlike his year-class mates who will be shadowing GPs and being eased into making their choices next year about their future specialisations without much expectations about their performance this year, he is acutely aware of being under an entirely different level of scrutiny. This is an assessment, even if it hasn't been referred to as one. Sharon Medyar is not on his side. She will report to Joseph Murray about today, of that Sherlock is certain.

_'You can't just refuse to deal with people, Holmes,' _Joseph Murray, the Director of Medical Education — also known as the Clinical Dean — had told him. _'Every student must learn how to deal with typical patient work scenarios and interactions with colleagues and other staff, regardless of what specialty they choose.'_

_'What is the point of that?' _Sherlock had demanded to know. _'I know what I want to do, and that I should be able to become rather good at it, and I don't need psychiatry or GP rotations for such a plan.'_

_'It's not for you to decide who will be given a chance to become a neurosurgeon,' _Doctor Murray had told him coldly. _'There is no path on offer where you'd be trained directly to just operate on people. That's not how the system works.'_

_'Then the system is clearly wrong!' _Sherlock had fearlessly told the man.

_'The operating room is a team environment,' _the Dean had pointed out, and though Sherlock was not good at reading people, he could tell the man was getting annoyed with him. People often did. He didn't always know why.

_'And that's fine, because there everyone has a specific job and they will all be focused on helping me do mine,' _Sherlock had countered. He may be just a second-year student, but he's not an idiot. He knows what he's in for. He doesn't need some _special _assignment where he gets exiled to some outpatient clinic to teach him what an operating room is for.

Which is why he needs to prove himself to Medyar so that she won't be as condescending as Murray had been. He has the nagging sense that he's expected to justify to Medyar why he's here, and he wonders what exactly Murray had told her. Lots of recently graduated doctors do taster weeks in different specialties, but second-year medical students are supposed to be focusing on book exams on preclinical subjects, not hanging out at the neurosurgical department.

"I'm about to publish the first part of what will be a PhD thesis on transcutaneous thermal convection analysis to assess cerebrospinal shunt function," he announces.

"That's very impressive," she confirms. "But Murray also says that concerns have been raised about your ability to work together with others, and to relate to your fellow students."

_He hates me. Just like the idiots he keeps referring to as my classmates. They're not my friends._

"Murray told me he thought it a good idea to give me a chance to see some of the practical side of the field before I start _chasing any decisions about my future_," he quotes the man who's had it in for him since the very first time a teacher approached him about his performance. "Which is why I should be in the OR, not here," he says with mild disdain, eyes scanning the appointment room.

There is a poster slightly worn at the edges of the human nervous system hung on the wall above the exam table, and a plastic brain sitting on the surgeon's desk. The nurse has a smaller side desk.

The look Medyar gives him is hard to interpret. Then again, people's expressions mostly are — at least to him. She turns the computer screen so that he can lean forward in his chair to read. They are the records of a sixty-four-year-old woman with a brain tumour that has been operated on twice. The latest operation had been a month earlier, and the scans taken soon after show swelling as well as large parts of brain tissue missing. It has always amazed Sherlock how much can be removed without utterly destroying a patient's ability to function. _How do surgeons decide when to stop cutting away tissue without monitoring function such as speech and limb movement? _He wonders and makes a mental note to ask Sharon this.

"What's the next step, then? Reoperation? There's clearly some tumour tissue left," Sherlock suggests.

"Palliative care. The pathologist's report shows that the malignancy of the tumour cells has increased. We could continue doing operations, but she has already lost many cognitive abilities, and we can't remove all of it. There's no cure for her, now."

He's surprised by the answer. His first instinct is to ask whether there could be another surgeon, a bolder one, a _better _one, who could remove even more. But he doesn't want to insult her. He needs to not insult her. Making a favourable impression on her could be important; neurosurgery is a competitive specialty to get into, and Sherlock doesn't underestimate the effect of connections and recommendations. Not after having watched his brother climb up the ladder of first being a government official and then a private sector tycoon.

"Why is she having an appointment, then?" He asks.

"So that we can discuss her care from now on."

"But why––" He frowns. "Why would a surgeon waste time on such discussions? Surely, anyone could deliver the news and then dictate a referral to hospice." _Talking to patients about things that are not connected to surgery — isn't that the job of the nurses? Or a GP? Or a psychologist?_

"What do you think is the purpose of a preoperative appointment?" Sharon asks.

The answer comes to him easily. "To assess whether the criteria are fulfilled that the patient would benefit from the surgery, to establish their eligibility for it and anaesthesia based on their cognitive and physical fitness and prior medical history, to decide if it should be a day case or if the patient needs war or ITU care afterwards, which preoperative consultations and examinations are needed, and to decide upon the best surgical approach, meaning technique, together with the patient."

"And what else?"

"That was the entire list, rephrased, from _Holborn's Diagnosis and Management of Surgical Disease_."

"Which I have no doubt you've memorised, but you're still missing one important part."

He hates this. He hates it when people trick him, when they demand he read between the lines, to interpret information that isn't factual. The seconds tick by as he sits silently, petrified by the sense of failure.

Thankfully, Sharon's expression softens. "That preoperative visit is when you get to know the patient beyond what their records say, and during that visit, you must get them to trust you with their life and their health. A part of that trust is the assumption that you will see them through their illness to its conclusion, whether that be a cure or the end. That you'll be there for them, with them, along the way. We don't just operate on brains and spines, Sherlock, we operate on people."

"Aren't there––" he starts nervously, then licks his dry lips, "Surely some surgeons focus more on the… surgical part."

"There's a time and a place for that focus, and I don't have to tell you what and where that is. But operating is just half the job."

"But this…" Sherlock sweeps his palm upwards to indicate the appointment room, "this is the NHS, which wastes a lot of resources by making surgeons do things which would be better suited to other specialties, even other healthcare professionals."

_Surely the private sector has found a way to delegate pointless chatter and tedious routines to someone other than the people who should be in the OR, doing what they do best. _All he needs to do is keep his head down, learn the necessary platitudes and social scripts to get through the theatrics of patient interactions in other compulsory medical school courses and the early stages of speciality training. He needs to bite his tongue and get through it all and then, _then _he can be a neurosurgeon and leave all that nonsense to registrars and House Officers and nurses and anaesthetists.

"I have to say I'm a bit surprised how little you seem to know about what a surgeon needs to do besides OR work. I have two days of outpatient clinic a week, plus ward duties."

Sherlock still thinks it's just bad organisation to assign a surgeon to do so much of those things. Surely there's some room for negotiation once one is a Consultant. Perhaps Medyar has agreed to it because she enjoys those things?

"Should we bring Mrs Hadley in?" The nurse, whose name Sherlock vaguely remembers to be Mark suggests, glancing pointedly at the wall clock.

"Of course," Sharon prompts.

Mark goes to fetch Mrs Hadley in. She moves with a walker and is accompanied by her husband and daughter. The hypothetical thought of having to tell bad news to three laypersons makes Sherlock highly uneasy — it's three against two, if they get upset or angry. _People can be so irrational when it comes to illness._

After the latest surgery, Mrs Hadley is suffering from double vision which has further impaired her ability to move around unassisted. She doesn't suffer from headaches, but vertigo has been a problem since the first surgery. It takes her some time to find words to create full sentences; occasionally she is clever at coming up with an alternate explanation when a word completely eludes her.

She takes the news Sharon tells her about the malignancy of the tumour increasing with quiet grace. The husband has questions and so does the daughter, and they seem resistant to the idea of palliative care. Suggestions of radiation treatment, new drugs, new surgery are brought forth by them and carefully dismissed by the surgeon. Sherlock cannot fathom from where she summons the patience to explain the same things again and again. She also keeps explaining things very simply, in non-medical terms, which irritates him. The language is imprecise, and there are gross generalisations being made. Couldn't a patient be expected to familiarise themselves with the pertinent terms and patophysiology of their own illness? That's what he'd do. _Having a surgeon explain things as though they were speaking to a child is a criminal waste of time_.

At the end of the appointment, which will be Mrs Hadley's last with this service, the family floridly thanks Mrs Medyar for everything she has done. They seem pleased with her, though by some measures she has failed, hasn't she? Of course, it's the location and grade of the tumour that have sealed her fate and not the surgeon's lack of skill, but how is Sharon not more frustrated than she appears? Why is she not scrambling to survey all potential surgical techniques to remove even more of the tumour, if she could? That's what she's said, that it was possible, but then she'd come to an agreement with Mrs Hadley that enough was enough when it came to loss of one's independence.

He's lost in thought while Sharon types up some notes. She occasionally glances at him, perhaps expecting questions, but he has none. Hopeless case, uninteresting location for a tumour, and the type is common. He is certain he's read up them it well enough that the next thing he needs to learn is how to remove them.

The next patient is a young woman with a meningioma — a benign tumour with easily distinguishable borders. It's not very big and growth is slow, but it's pressing on her olfactory nerve and for a culinary student, it's a disastrous problem.

She has also broken up with her boyfriend, and is pouring out the related anguish, plus her fears about brain surgery by succumbing to hysterics. Twenty-five minutes of the thirty-two-minute appointment is spent discussing things which to Sherlock seem to have very little to nothing to do with her brain tumour. _Why do patients not understand that this is not the time or the place to solve their socioeconomic life problems?_

Sharon had rolled her chair in front of the patient and has laid a hand on her shoulder, presumable in an attempt to console her. Sherlock doesn't want to touch patients beyond examining them and has no clue when polite and socially motivated gestures would be welcome or advisable. They might also be misinterpreted and thus risky. _Best avoided_.

"You look… perhaps not bored, but a bit uncomfortable?" Sharon suggests after the patient has left.

"Why didn't you make her wait outside until she'd calmed down?" Sherlock asks.

"She needed to get all that out before she could listen."

_Couldn't she have 'got all that out' at a family member or a friend? _Sherlock wonders. Sharon doesn't seem the least bit disturbed by the flood of emotions, which has already been directed at her, and it's barely even gone nine in the morning. Sherlock is exhausted second-hand even from just watching this debacle. He refuses to accept that this is what a neurosurgeon does. It must be Murray's idea of a joke to send him to observe some exceptionally touchy-feely member of the profession to discourage him from pursuing that path. He'll find others to model his practice after, and he'll do it alone. As long as he excels at his written exams and goes through the motions of what is expected at OSCEs and other practical tests, they can't stop him.

Sharon talks him through the surgical plan for the meningioma removal, and he begins to feel much more at ease discussing technical and anatomical details. He can't wait to advance to the later stages of his medical schooling which will allow him into operating rooms, assisting and then doing things himself. He's always been good with his hands and the violin has further increased his dexterity. He has even snuck into the clinical labs at the medical school to practice stitches and scalpel technique on meat he's bought from the butcher shop.

He has no illusions about the difficulties he'll have in interviews and patient interaction, so he needs the trump cards of his practical skills and his fledgling research career to stand out from his peers. The peers who hate him and would want to see him fail. They think he's obnoxious, a bookworm, a know-it-all arsehole — they've _told _him so. They've had it in for him from the very first weeks of anatomy lab, especially Wilkes whose butchering of the brachial plexus he just couldn't watch from the side-lines, so he had involved the instructor and had Wilkes banished from holding the scalpel as they continued to dissect the layers of their cadaver, peeling off skin and muscles and other soft tissues to get into the nerves and the blood vessels. When the other students had despaired over trying to learn the complex nomenclature associated with all the nooks and crannies of the skull, he had loved it all, as he had learning all the parts of the brain and the cerebrospinal fluid system. It was astounding how a person's memories and personality could live in such a lump of gnarly tissue as the cerebral cortex, and how it could learn and adapt even after devastating injury. The other students seem to just think they are going to university as some sort of lifestyle choice, having to endure tedious classes until they could attend their parties. Are they not there to learn medicine? Sherlock clearly has nothing in common with them, and he doesn't quite understand why many of them had even chosen the profession. If they don't care, if they aren't motivated to learn human anatomy or physiology or pathology, why are they even doing this — unless pretending disinterest was somehow socially expected. It makes no sense either way, and Sherlock wants nothing to do with that lot who drink, copulate, show up at exams hung over and seem to be utterly oblivious to the astonishing work of art that is the human central nervous system.

Sharon lets him examine the next patient without telling him anything about what is ailing them. He does a thorough job of it, then verbalises his deductions of where their obvious brain tumour is located and why it is producing these particular symptoms. When she shows him the scans, they prove he has been precisely right.

The patient, an older man who is a schoolteacher by profession, voices his amazement when he realises Sherlock had made his diagnosis based on just clinical findings and his knowledge base. "This one'll make a fine surgeon, won't he?"

"We shall hope so," Medyar says calmly, then begins discussing the upcoming surgery.

Though her words are irritatingly ambiguous, Sherlock beams. Finally, a _patient _has confirmed that surely the most important things are knowledge and competence, not knowing the right moment to pat someone on the shoulder or knowing how to reassure them their life won't end even though they have to move out of a flat shared with a boyfriend.

There are many ways to be a good surgeon. Dean Murray is a _paediatrician_, for heaven's sake — only people uniquely tolerant of nonsense would choose such a speciality. What could Joseph Murray know about neurosurgery?

The next three patients are post-operative follow-ups, mostly uneventful. In Sherlock's opinion they could easily have been turfed to a junior surgeon, but Sharon seems to enjoy surveying her handiwork. Perhaps there is a modicum of satisfaction that can be gleaned from patient praise, but since they lack the expertise to assess a surgeon's professional competency, they're hardly anything to be taken too seriously.

A quarter past noon, Mrs Medyar and her nurse take some time scheduled for a lunch break. Their schedule is running late so they'll have to make haste in eating.

"You're welcome to stay for the afternoon session as well," Sharon tells Sherlock.

"I have lectures," he replies. It's likely he won't attend those lectures because most of the pharmacology lecturers are rotten at public speaking and teaching; he can study the material much faster and more effectively by staying in his college room with his nose buried in a book. Besides, he's already read all the requisite material for the course, and his eidetic memory spares him from having to revise for the exam in two weeks.

"Thank you for this opportunity," he says to Medyar, because he has learned that one should always thank a supervising physician even for compulsory teaching. He keeps his hands tucked behind his back. There is plenty of research evidence that says the shaking of hands should be banned in hospital for hygiene reasons.

"My pleasure. I will see you in the OR in a few years, once you start your surgical courses."

He nods and slips out the door, realising only after the fact that he should have perhaps said goodbye to Mark the nurse as well. He knows nurses are prone to making complaints about young doctors if they are perceived to be too cocky. Then again, why should he care? His duties as a graduate doctor won't be to be nice to people, it's to get through his rotations and then apply to neurosurgical specialty training. Until then, he'll just have to grit his teeth and endure.  



	2. Final Year

  
"Bloody Holmes is scrubbing in with Medyar _again_! At least he's such an arse that they'll never accept him into neurosurg. Best get his cutting kicks now while he still can. You should have seen him at anatomy lab in year one, I bet he had a hard-on."

Matt Lydyard doesn't even lower his voice when Sherlock walks past the group of students he's holding court with loitering by the board of the Addenbookes Hospital OR floor. After Sebastian Wilkes had been kicked out of the medical programme, the social power vacuum left by him had unsurprisingly been filled by other upper-class twits, Lydyard first and foremost. He'd been Wilkes' friend, and despite the reasons which had led to his dismissal, Sherlock is certain they'd have rather seen the back of him rather than Wilkes'.

_Only a year left with these idiots_. All who have gathered on the OR floor this morning are hopeful candidates for surgical training, doing their final medical school apprenticeships lasting six weeks before the application and interview process for postgraduate training begins. Most of them will rotate through numerous surgical specialities after what are known as the two Foundation years — the first years after graduation — but for neurosurgery, the path diverges early after the compulsory two years of serving the NHS as F1 and F2 junior doctors. Most of Sherlock's peers rejoice over having a few years after the Foundation stage to consider what they want to do with their careers, but he would never have chosen that option. He knows what he wants, and no amount of taunting from other students, no amount of counselling and discouragement from staff, is going to make any difference.

Lydyard puts an arm around the young woman standing beside him, giving her a suggestive squeeze. "Trust the freak not to know what's good for him. I know what I want, Amy, and it involves you, me and a bottle of wine tonight, just for starters. The only date Holmes is ever going to get is with his left hand."

Sherlock doesn't break stride, doesn't stop to verbally eviscerate Lydyard even though he knows he could do so by revealing to his beau what Sherlock can read on the man about what he'd been up to last night. He knows what he wants, what he's wanted since Victor left him and he left Victor, and that's what he needs to focus on, not petty squabbling with fellow students. Things with Wilkes had gone too far, and even though he wasn't responsible for the worst jumps overboard, he could have put an end to it earlier. _Lesson learned._

Just like he'd learned another kind of a lesson about getting involved with people from Victor. He doesn't think about Victor these days, not really. That was his one attempt, his thorough education at romance, and he's taken it to heart. He's simply not equipped for that sort of thing. _I'll be married to my work, and that's all._

He takes a deep breath, banishing his annoyance over Lydyard's taunting. He knows that, once he's scrubbed in, instruments in hand, the rest of the world will fade away. In theatre, he feels like he belongs. None of the anxieties that had derailed him in the summer follow him into the OR. He can put what had happened away, locked up tight — as long as none of his classmates don't make references to the details. He's certain that certain rumours about what had happened have circulated the student body, but thankfully — apart from Lydyard and his ilk — most of the students just steer clear of him and don't ask about whether certain things are true.

Compartmentalisation is what the therapist had called the ability to push things away, file them somewhere in the deepest levels of his Mind Palace and never look at them again. The therapist had even stated that doing so was ‘a necessary skill for a surgeon’. As long as Sherlock doesn't end up in the same Trust for his neurosurgical training as his classmates, he'll be fine. _I'll have a fresh start_.

Today he'll be assisting one of Sharon Medyar's trainees with an evacuation of a subdural haematoma. A simple burr hole procedure of not much anatomical interest, the benefit is that he might get to perform some of it if the trainee is in a charitable mood and confident enough to teach instead of focusing on their own performance. Sherlock ties a mask neatly on his features, bends the metal wire inside the part covering the nose so that it will be comfortable, and checks that all his curls are tucked neatly inside the disposable hat. He means to buy some personal, fabric ones once he's a trainee proper.

He conscientiously washes his hands, even brushes his nailbeds. Once he's dried his hands with tissue, he douses them with disinfectant gel and lets it dry, resisting the urge to waft his hands back and forth in the air to speed up the process — the hygiene unit would frown upon that. A glance through the plexiglass window separating the washing area from the operating room tells him his timing is impeccable: the scrub nurse is setting down drapes on the anaesthetised patient, and all the instrument trays have been neatly arranged onto sterile drape -covered tables. The surgeon has not entered yet, so Sherlock will be able to score some punctuality points by being there before him.

With his foot, he presses a plate down low next to the door to open it, then walks in holding his hands above his waist, careful not to touch anything. A sterile gown has been placed on a side table which he picks up carefully, spreads it as he has been taught — in a way that won't contaminate the front, and slips his arms in. The supervising nurse steps closer to tie the ribbons around his neck and his waist, after which he offers her the piece of cardboard holding the belt together. While she holds it, he spins until he can pull the other end off the cardboard piece and tie them neatly. He then walks to the instrument nurse who helps him don his gloves.

Such rituals with their rehearsed movements are something that he has learned to love; they steady him, clear his mind. He's ready and eager to get going.

But his luck runs out when he sees who's now entering the OR from the washing area. It's Joe Manheim, one of the trainees, instead of George Glass who Sherlock had been expecting according to what had been written on the board. Manheim is known for being a slow learner and has not shown much promise as a surgeon, and Sherlock has no idea why he hasn't been kicked out of the training program yet. Manheim's theoretical knowledge is sorely lacking, and it seems as though he's never even bothered to open any of the essential textbooks in the field.

And he always does everything himself; won't even let medical students do the final stitches. _Still, there's no harm in asking, is there?_

"Could I do the opening incision and the subgaleal drain?" Sherlock suggests.

"Who the hell are you?" Manheim asks, looking at him askance as he adjusts the cuffs of his surgical gloves.

"Sherlock Holmes. I'm doing my elective rotation."

"You're a student?"

"Yes." Sherlock grits his teeth. What does it matter what he is? He knows this procedure in _theory_like the back of his hand, and if they'd only let him get a head start in learning the practical side of it…

"You can watch," Manheim says, and turns his back on Sherlock. "Medyar would decapitate me if I let you put your hands on the patient," he mutters, making the first incision.

"No, she wouldn't," Sherlock argues. "I've scrubbed in with her sixteen times."

"You're a medical student and this is _neurosurgery_," Manheim says incredulously, pronouncing the word slowly as though speaking to a child. "Next you'll be telling me she let you clip an aneurysm." He chuckles and cauterises a tiny subcutaneous artery.

Sherlock knows from overhearing break room talk that the scrub nurses openly dislike Manheim: he dismisses their advice, barks incomprehensible commands at them for instruments. _How difficult can it be to pronounce Kairison?_he wonders, watching Manheim clip the scalp less than elegantly so that the flap of it won't slide onto the opening in the skull, obstructing the view.

Sherlock has discovered that if scrub nurses find a trainee or a student tolerable, they might help by giving advice or offering the right instrument without prompting. Some of them take mercy on medical students when they're being grilled by surgeons about correct technique or instrument names, and covertly give good hints. Sherlock needs no such thing, of course; he knows what everything is called and what is needed at any stage of the most common intracranial or spinal operations. All he needs is practical experience and for that, he needs an Educational Supervisor to fill out a form that will be a part of his application. Since neurosurgery training is highly competitive to get into, that assessment form needs to come from a major player in that field. At Addenbrookes, the golden ticket is undoubtedly Sharon Medyar, who had risen in the ranks to unit head in the year prior. Sherlock believes he's managed to garner some favour with her; she has repeatedly commented positively on his knowledge base and his research. Surely, she would support his plan?

_None of the other applicants will stand a chance when it comes to academic credentials_. Sherlock knows it for certain; at conferences he's attended by paying for the fees himself or borrowing money from Mycroft, he has heard other late-stage medical students discussing their applications and registrars discussing the process from hindsight. He knows what most Trusts look for in a candidate. They _have _to take him. They can't _not _take him. He will not consider the possibility of failure. The doubts that had plagued him in the summer have not disappeared, but if he can't hang on to his dream, what would be left?

If they accept the likes of _Joe Manheim _to neurosurgical training, then Sherlock should breeze through the application process.

His confidence boosted by this introspection, Sherlock gives himself permission to tune out of the start of the operation since it's dull and he doesn't get to do anything. Manheim doesn't engage in teaching, doesn't ask Sherlock any questions because he'd probably prefer all medical students to make themselves scarce when he's holding a scalpel.

Late into the operation, Manheim begins shifting on his feet. He seems eager to close, but a very persistent small artery keeps filling the surgical field. From his spot, Sherlock can see that it's being kept open by a small, remaining piece of old haematoma which Manheim either doesn't care about or hasn't noticed. The registrar keeps trying to dab the bleed with cotton swabs, even shoves in some Surgicel — absorbent local haemostat material — and finally begins retreating his instruments out of the burr hole.

"It's still bleeding," Sherlock catches himself saying.

"No, it isn't. It'll contain itself."

Sherlock ignores the contradictory nature of that statement. "The plasmin forming in the old clot will keep dissolving the Surgicel," he argues.

Manheim points a finger at his face. "You. Shut it."

From the edge of his visual field, Sherlock can see that the field has flooded again. "Just _look _at it."

"It'll limit itself. One more word out of you, and––"

"Oh, for Christ's sake!" Sherlock exclaims, grabs the suction and empties the surgical field of blood. He nimbly directs it just underneath the edge of the bony hole and removes the rest of the old clot. The artery is now clearly visible, and it is now bleeding in earnest again. That was to be expected, but now it can be ligated or cauterised properly.

"Now look what you've done!" Manheim bellows. "Get the _fuck _out of my OR!" He turns back to the draped surgical field, cauterises the artery once again, and this time, the haemostasis holds.

"Gladly," Sherlock replies and tears off his gloves.

Manheim will make waves about this, he knows it. He knows he's made a mistake — not in stepping in to manage the bleed but in stepping on Manheim's toes. He has watched Medyar and other surgeons do this procedure six times, now; he has observed what steps she takes to control similar arterial bleeds by eliminating the possibility that fibrinolysis might cause a rebleed after the wound has already been closed. It could be that Manheim hasn't been paying attention to what he's been taught, or that he's simply an idiot. Either way, he is a neurosurgical registrar and Sherlock just is a neurosurgical… nothing-yet.

______________  
  
  


The waves hit the shore two days later, when Sherlock is summoned to the Director of Studies' office.

Murray, his old adversary, does not hide his disdain. "You were told not to interfere, and strictly told not to offer further commentary by a supervising physician. What on Earth possessed you to do such a thing?"

"He was hardly supervising me, since he wasn't allowing me to do anything," Sherlock replies coldly.

Sharon Medyar is sitting in the chair beside him. At least Manheim isn't in attendance; there's no need, since the matter has naturally been escalated to the head of the neurosurgical unit.

"In all my years, Holmes, I have never had to consider what to do with a student who _took over an operation_." Murray shakes his head.

"It would have been unethical _not_to take over," Sherlock protests. "Manheim refused to listen to reason, and the patient could have been left bleeding, leading to a reoperation or possibly a severe complication if the arterial bleed had been missed. That is a perfectly plausible risk at the neurosurgical ward that's always understaffed, and half of the nurses have no idea how to assess acute emergencies, anyway."

"That's quite enough from you, Holmes," Medyar says firmly.

"I thought the purpose of this assembly was that I could give my account of the events."

"There were three other people in the operation room besides you, all of whom have given their accounts."

"And it's in all of their best interests to blame the student to save their hides."

"This is not some conspiracy, Holmes. This is about _your _conduct, and your conduct only."

"So, it doesn't matter _why _I did it?"

"I know you are very enthusiastic about surgery, but we can't allow that to blur certain safeguarding principles."

"Safeguarding principles? Is it not a physician's duty to prevent a patient from coming to harm? If I see a mistake being made, should I not speak up?"

"Speaking up is a whole different thing to shoving someone who is your senior aside and grabbing an instrument. You're lucky the outcome was good; the Trust could have been sued for negligence in student supervision."

"Luck had nothing to do with it. Manheim was about to ignore an active, potentially disastrous bleed, and close up. He wouldn't listen to what I told him about why haemostasis would be compromised. His ego was more important than the patient's outcome. I don’t think that's professional."

"Manheim's management of the case will be under review," Medyar says amicably.

But Murray snaps, "Respect for our seniors is an important part of professionalism, Holmes! There is a proper manner in which to raise such concerns with seniors, and it is decidedly _not _by grabbing an instrument! Developing good habits of collegiality is a critical learning outcome of your rotation assessment."

"And saving patients isn't?"

Both Medyar and Murray are now giving him a stern look. It seems that arguing what Sherlock sees as the only pertinent point will not erase what they've decided to focus on — the way he has overstepped his mandate as a student.

"Will there be disciplinary action?" Sherlock finally asks, resigned.

"After carefully weighing all the factors and the outcome, it has been decided that no such action will be taken, apart from shifting you elsewhere for the rest of the surgical rotation. There is a spot in dermatology due to a student's sick leave."

He rolls his eyes. Dermatology would be the last clinical specialty he'd pick. Well, possibly he'd want to pick GP or psychiatry even less. Or paediatrics. Or obstetrics. Or––

"Use this opportunity to cool off, to explore other areas of medicine. Neurosurgery is not the only option," Dean Murray assures him.

His words frighten Sherlock, and he turns to Sharon Medyar. "I wanted to ask… Does this mean you won't fill out an Educational Supervisor's report for my application?"

He _needs_that report from her. He won't be doing a long enough neurosurgical rotation during his Foundation years — in fact, he might not be assigned to any at all — so her assessment is vital as an appendix to his application. Otherwise he'd have to spend years scraping together junior Trust grade jobs in neurosurgery with the hopes of finding some kind of a mentor of her calibre who might be willing to endorse him. It _has_to be her, or his training might be delayed for years. _I'm not wasting time assessing bunions and writing amoxicillin for old ladies' urinary tract infections for a minute more than I am obligated!_

"Of course I will fill out a Supervisor report; I'll have to sign off on your rotation, anyway," Medyar replies, but her tone is now less cordial than what he's used to hearing from her.

He has already declined to apologise to Manheim. This didn't go down well with Murray after he had made the demand in his email summoning him to this meeting. Sherlock knows that this incident will likely also mean that there's no point in applying to Addenbrookes for his speciality training, but that doesn't matter — it isn't where he wants to be. No, what he wants is The National Hospital for Neurology and Neurosurgery in London, and he won't settle for anything less. All the more reason to need a Supervisor Report from someone like Medyar, instead of just some no-name neurosurgeon in a regional unit. At least this is Cambridge, a name which still means something in medical circles.

Just like he hopes his own will, one day. The only problem are the Murrays and the Manheims standing in his way.

"I do have to be honest in my appraisal, Sherlock," Medyar says with some disquiet. "The results of your clinical finals were exemplary in most areas, but this is not a good note on which to end your apprenticeship block.”

"Then let me finish it," he pleads feebly.

Before walking out, Mrs Medyar gives him the same sort of resigned look his mother cultivates when she’s decided he’s too hopeless a case to understand anything. "With the right training, you will be great at operating, but you've got a long way ahead of you in learning how to be a _doctor_."

**Notes for the Chapter:**

> You may wonder what went down between Sherlock and Sebastian Wilkes. All will be revealed in detail in a future story of this series.


	3. The Interview

"Good morning, Mister Holmes; please, take a seat."

He's not nervous, not in the way that the other candidates must be; instead, he's antsy to get through this formality and begin his career proper. That said, he is also well aware that there are thirty applicants for every spot available in neurosurgical training in the UK. While Sherlock has no doubt that he could land a place at some other Trust, this is the National Hospital for Neurology and Neurosurgery — the most prestigious one of them all — and the competition for its three annual trainee posts is incredibly fierce.

For the past two years, he has endured the scut work of a Foundation doctor: drawn bloods, ferried around the samples taken, chased down radiologists, renewed medication orders, written prescriptions, written up fluid plans, began more IVs than he cares to remember, argued with nurses, argued with patients and family members, argued with his seniors. He'd rotated through an understaffed and malignant cardiology unit at Royal Papworth, got his bearings around fast-paced A&E work at the much smaller Hinchingbrooke Hospital in Huntingdon, after which it was back to Addenbrooke's for neurology, internal medicine and otorhinolaryngology. He'd hated most of it, save for the occasional chance to leave the pedestrian ward tasks to some locum or House Officer and make his way to the OR to see if he could scrub in for something. At ORL they had given him his own outpatient clinic patients, which was fine since he got to perform many smaller procedures, but it prevented him from clocking in as much hours in theatre as he would have wanted. He'd developed an interest in ORL pathology and anatomy during that rotation; it surprised him that he hadn't realised how profoundly anatomically married that speciality was to neurosurgery. Perhaps there was a niche there he could explore in the future.

Sherlock has appreciated the mindsets of many of the surgeons he has met during his F1 and F2 rotations; as long as he knows his stuff, is capable at holding a retractor and doesn't faff about when asked to do something, they let him be and even teach him things. As long as he stays on the OR floor, everything is quiet and good and there are very few conflicts. Some of the seniors he has been supervised by have seemed to share Sherlock's frustration in the paramedical issues plaguing outpatient clinics: emotional outbursts, social problems, irrational behaviour from patients and their relatives. One such surgeon had agreed to write Sherlock a reference for his training interview even though he hadn't been on a predominantly surgical rotation at the time. The hitch is that the man is a gastric surgeon, so Sherlock is not certain how much such an endorsement will weigh against the less favourable ones in his CV.

If it hadn't been for the research projects he'd managed to talk his way into during medical school and his Foundation years, he might have gone mad from the mundane bits of everyday medicine. There are references from three research project directors, all testifying to his commitment, theoretical knowledge and originality. He's been steadily building the foundations for a PhD, knowing that as soon as he gets into the specialism, he should be able to start work on a proposal for a PhD clinical fellowship at the National, funded by the Wellcome Trust. The combination of research and clinical surgery is would be the perfect blend for him, and vocally striving for that should guarantee him a training post. He's ready, willing and able; he just needs to ace this interview and then he can finally, _finally _get started on the career he's been waiting for.

There's just one problem. 

The printed sheets of Sharon Medyar's Structured Educational Supervisor's Report for Neurosurgery sit on the table before the four panellists as well as his CV, his medical school records and a list of his publications. It has the potential to destroy his chances here and he knows it. In fact, to be honest, given what he knows is on those sheets, he's lucky to have been given an interview, considering how many applicants are rejected based on fewer red flags raised. He couldn't have left it out of his portfolio, because they would have asked about it; it's plain as day in his records that he's served in her unit. He can only hope that his research CV to compensate for her words.

His fate will now depend on the people sitting across the table from him. He clears his throat, straightens his back and forces himself to make eye contact. He recognises two of the panellists as well-known Consultants at the National. The third must be some faculty admin person representing the medical university affiliated with the training scheme. The fourth is bound to be a representative of the Trust a part of which is the National Hospital for Neurology and Neurosurgery.

The panellists introduce themselves; one of them is a neurologist at Oxford, there to provide an outside opinion. The neurology rotation at Addenbrooke's was the only part of Sherlock's Foundation years he could say he had enjoyed to any extent. He knew beforehand that the things he would learn there about examining patients would be important for his neurosurgical knowledge and learning about the conservative treatment of many illnesses and injuries he would tackle as a surgeon was invaluable. The evaluation from that period is also on the table, and Sherlock knows it's good, but is it good enough for The National, which is the nation's crown jewel in its field? This is where he wants to train, this red brick building beside Queen's Square in London, where many of the best neurosurgeons in history have had their start. He'll be interviewing at several other renowned units in London as well, but this is the one he wants.

Only if Medyar's report won't sink his chances.

The interview proper starts with what one would expect: _'tell us a bit about yourself'_, _'what are your strengths_', _'why do you want to pursue neurosurgery'_. Sherlock has formulated answers ready for these years aho, meticulously planned and eloquently worded with the help of countless books about successful interviews for years. Social scripts are something he's learned to master over the past years.

There are nods and interested, even impressed looks from the panel — especially when he's asked to give a summary of his research and his future plans to continue those lines of scientific interest.

"We like to start with the positive, then go through the Supervisor's Reports and additional references, then address any concerns the panel or the supervisor have expressed," Mrs Rowan-Reed tells him; she's the representative for Cambridge medical school's postgraduate training.

The panellists hum through what she summarised concerning the other training reports, and Sherlock half hopes they'll group Medyar's in with those. But, when the name does not come up, he knows they'll pick it apart later, once ice-breaking pleasantries are over and done with.

"Moving on, then," another panel member then remarks dryly. "Have we a report from a neurosurgical rotation?"

"Yes," Mrs Rowan-Reed answers. "From a Mrs Sharon Medyar at Addenbrooke's. She hardly requires an introduction, does she?"

There are dry chuckles around the table. Sherlock is the only one not smiling. Though he knows the answers by heart, he still hastily digs out his own printed copy of the report so that he can follow the discussion as best he can.

The option '_no' _is ticked on the first page report for the question _Are you aware of the candidate being the subject of any formal disciplinary processes?_. After that, come the assessments for knowledge, professionalism and personal attributes. _Clinical knowledge and expertise: A/Excellent. Professional integrity: B/Often shows respect to others, is generally aware of ethical issues. Comment: difficulties in respecting vocational seniority. Problem-solving and decision-making: A/Thinks beyond surface information, uses a range of problem-solving strategies. Comment: Outstanding diagnostic reasoning. Organisation and planning: A/Excellent at managing own time and prioritising workload. Comment: excellence in management limited to work duties; concerns raised about self-care. Learning and development: A/Actively seeks out constructive criticism/feedback and development opportunities. Comment: This applies to medical knowledge and surgical skills, but the candidate does not recognise obvious areas needing improvement regarding interpersonal skills. Working under pressure: A/Always remains calm under pressure, rapidly adapts to changing situations._

Sherlock is not surprised that the ones with As and Bs are not discussed during the interview. As for the other areas assessed…

_Communication skills: D/Uses technical language that others do not understand, ignores what they have to say._

'_You have to explain things to the patients in a way that they'll understand,' _Mrs Medyar had told him repeatedly. _'How can they make decisions about their health if they don't understand the issue or their choices?' _Sherlock had argued — repeatedly — that they were _laypeople_, that they shouldn't even be making those decisions.

_Empathy and sensitivity: D/Is not sensitive to the feelings of others and treats them in an impersonal manner._

Sherlock doesn't think this is quite accurate. If and when he understands why someone feels the way they do, he may well feel empathy towards them, but never quite knows what to do about it or it takes him so long to analyse the situation that he has already been judged disinterested and cold. He can't read people, and nobody ever explains him anything! They just expect him to know what to do and say, and mostly it just fills him with such dread than he nearly crumbles under the pressure. The word 'personal' also confuses him; his colleagues, nurses and other staff are not his friends; why should he get very personal with them?

_Managing others and team involvement: D/Sticks rigidly to their own agenda, critical of others' ideas. Comment: capable of working with others as long as everyone has well-structured roles, but rather than true teamwork, this is parallel work with others._

The panel asks Sherlock to comment on these crushing answers.

"These things are not taught in medical school, nor are there such educational opportunities available during Foundation training," he parses together.

"So, you blame the medical education system?" One of the two surgeons on the panel asks. "Books and courses are not the only nor are they the best way to learn professionalism and bedside manner, Mister Holmes. These, we learn primarily by example."

"I cannot tell which examples are good and which ones aren't. Research evidence says that emergency leadership skills can and should be taught, and I have thus attended numerous simulation-based courses to that effect," he offers.

The surgeon's mouth pinches into a line and Sherlock knows he's far from satisfied with the answer.

"The primary concerns regarding your professional conduct are not associated with emergency leadership. They're to do with everyday interaction with patients and other hospital staff."

_Most of whom are incompetent idiots_.

"I find your application uniquely unbalanced," the Trust representative says. "Your research and academic credentials are second to none, so the question is: can you take responsibility for the care of patients in a way that will satisfy their expectations?"

"Their expectations should be based on the medical quality of the work. Sadly, few patients have the technical knowledge to be able to assess that, and even the NHS has fallen into that trap by introducing feedback systems which measure more people's mood regarding the weather or the taste of the coffee at the hospital canteen than they do the quality of the actual healthcare services they've received." Sherlock is thinking of the smiley and grumpy face feedback buttons on the machines the hospital he had last rotated through had introduced at the entrances. So what if 34 % of people pressed the smiley face? The machine provided no data as to _why _they were content or dissatisfied.

He adds, rather lamely, "Neurosurgeons have patients, not customers looking for a _comfortable__, reassuring __experience_. What they should be expecting is for their medical issues to be operated on in a timely and skilled manner."

Jan Andreason, a famous neurosurgeon nearing retirement age, leans forward in his seat. He's been silent so far. "Curiously, Mrs Medyar says that she would be happy to work with you again, despite her concerns and the fact that she has chosen option C in the question whether she'd recommend you for training in neurosurgery, meaning that she has serious reservations. What is your take on this discrepancy?"

Sherlock swallows, studies his shoes until lifting his chin to face the older surgeon. "What I lack has _nothing _to do with medicine. During my time with Mrs Medyar we repeatedly debated the differences between her definition of a surgeon's role in patient care and my views on the topic. Possibly she thinks that, with time and the right mentoring, I could learn to see her viewpoint."

"We are not here to recruit people who are ready and complete in their training," Andreason says. "As much emphasis as we put on social skills, there are plenty of empathetic, great doctors who could never be good surgeons. As great as they are as physicians, this field has no use for them. What I want to know is whether you are ready for your beliefs and ideas about what it is to be a surgeon to be challenged."

"Yes, of course. As you said, I am applying for training, not a Consultant post."

"In that case, I would like to stop talking about boxes ticked and to speak about surgery," Andreason says in a tone that invites no arguments from the other panellists. The senior surgeon then launches into an immensely detailed, brutal questioning of one of Sherlock's research projects — a novel design for an anti-siphon shunt. By challenging his postulates and knowledge, Andreason meticulously tests Sherlock's understanding of the intricacies of the flow and creation of cerebrospinal fluid. He then asks Sherlock to describe, step by step, the installation of an Ommaya reservoir — a relatively uncommon procedure no Foundation year doctor or medical student should be familiar with.

Sherlock rattles off the answers as though he's been asked something as simple as the location of the nearest gent's. This is what he's here for and finally, _finally _there is a senior panellist who seems to share that sentiment!

His interview runs ten minutes overtime as Andreason continues to interrogate him even further, delving deep into brain tumour classifications and cerebral aneurysm typing. Finally, he nods at the chairperson, and the panel dismisses Sherlock from the room.

He has no idea if he has done well or rather badly, and he feels he possesses not the skills to assess whether the interview will have enough weight to offset the crushing parts of Mrs Medyar's report.

  
________________  
  


Two months later, the letter arrives.

_"The National Hospital for Neurology and Neurosurgery welcomes you as one of our new neurosurgical trainees for induction week starting on the 10th of August…"_

Clutching the envelope in his fingers, tears glistening at the edges of his visual field, he thinks about Victor and what Victor might think about all this. Then, he goes to call his mother.

He's going to The National, and he's going to show them all that he belongs there.

**————— The End —————**

**Notes for the Chapter:**

> There are plans for more glimpses into Sherlock's formative medical years but in the next part of the series, we return to present times as Sherlock and John prepare to take on a high-profile case. here's no definitely publishing schedule planned yet, but rest assured that Doctors Holmes and Watson will return quite soon.
> 
> The questions and answer options used in this chapter are from a real trainee assessment form used in the UK.


End file.
